The present invention provides an improved surgical access device of the type which is used to gain access to an internal cavity of a patient""s body. A preferred embodiment of the invention is useful both as an access port and as a tissue retractor.
Surgeons frequently need to gain access to patients"" body cavities to perform various procedures. One way to gain access to such a cavity is to perform invasive surgery where the cavity is opened fairly widely from the exterior to allow the surgeon ready access to the interior of the cavity. For example, in most traditional heart surgery, the patient""s sternum is split and the overlying tissue is cut back to allow the surgeon to place both hands inside the chest cavity.
Increasingly, however, less invasive techniques are being employed to permit access to body cavities. For example, endoscopic examinations are being used to explore body cavities without having to directly visually inspect them. Gall bladder surgery is also being done increasingly by gaining access to the abdominal cavity through smaller access ports through the abdominal wall rather than using more invasive approaches. (See, for example, U.S. Pat. No. 5,375,588, issued to Yoon, the teachings of which are incorporated herein by reference.)
Increasingly, surgeons are gaining access to the thoracic cavity by passing surgical instruments into the cavity through the intercostal spaces between a patient""s ribs. For example, U.S. Pat. No. 5,613,937 (Garrison et al., the teachings of which are incorporated herein by reference) suggests a method of conducting closed-chest heart surgery by passing surgical implements through a number of ports positioned in the intercostal spaces. This patent shows one access cannula which provides an oblong opening which allows a surgeon to pass a replacement valve into the thoracic cavity for placement in the patient""s heart.
A wide variety of surgical retractors are also known in the art. Most surgical retractors are intended to allow a surgeon to forcibly urge tissue out of the way to enable unfettered access to the underlying anatomical structures. For example, U.S. Pat. No. 4,765,311 (Kulik et al., the teachings of which are incorporated herein by reference), shows a xe2x80x9cwound retractorxe2x80x9d which comprises a split tube. Each of the two tube halves are carried on holders which can be moved apart from one another to retract the tissue and provide access to the abdominal cavity. U.S. Pat. No. 1,157,202 (Bates) teaches a retractor which is used to retract the sides of an incision in the abdominal wall. This retractor includes four separate retractile elements which are arranged about an oval frame. The tissue can be pulled apart to expand the size of the opening of the incision by pulling the retractile elements away from one another.
U.S. Pat. No. 5,125,396 (Ray, the teachings of which are incorporated herein by reference), suggests a surgical retractor which comprises two separate arcuate blades. Each of these arcuate blades is carried by a separate ring. By turning these two rings with respect to one another, one can move the blades with respect to one another to open a generally cylindrical passageway through the patient""s tissue.
The present invention contemplates both a surgical access device and a method of gaining surgical access to a body cavity. In accordance with one embodiment, a surgical access device of the invention has a frame defining an access port and this frame has a lower surface. A first flange having an elongate leading edge is carried on the lower surface of the frame adjacent a first side of the access port. The first flange is pivotable between an insertion position and at least one retracting position. A second flange, which also has an elongate leading edge, is carried on the lower surface of the frame adjacent a second side of the access port, the first and second sides of the access port being opposite one another. Like the first flange, this second flange is being pivotable between an insertion position and at least one retracting position. Each of the first and second flanges are shaped so that when they are both in their insertion position, their leading edges are positioned immediately adjacent one another and together define an elongate, generally linear leading edge of the device which can be inserted into a single, elongate incision. This leading edge of the device is positioned below the access port. In a preferred arrangement, the first flange is attached to the lower surface of the frame by a first hinge and the second flange is attached to the lower surface of the frame by a second hinge, with the first and second hinges being parallel to one another and extending generally longitudinally along the lower surface of the frame.
An alternative embodiment of the invention also provides a surgical device for accessing a body cavity. This device includes a frame defining an access port, the frame having a lower surface. A first flange having an elongate leading edge is attached to the lower surface of the frame adjacent a first side of the access port via a first hinge and it is pivotable between an insertion position and at least one retracting position. A second flange having an elongate leading edge is attached to the lower surface of the frame adjacent a second side of the access port via a second hinge and is pivotable between an insertion position and at least one retracting position. The first and second sides of the access port are opposite one another and each of the first and second hinges extend generally longitudinally along the lower surface of the frame. These first and second flanges are shaped so that when they are both in their insertion position, their leading edges are positioned adjacent one another and together define a leading edge of the device which can be inserted into a single, elongate incision. Preferably, this leading edge of the device is positioned below the access port.
In accordance with another alternative embodiment of the invention, a surgical access device includes a frame defining an access port and this frame has a lower surface. The frame also includes a pair of laterally extending wings having a concave lower surface extending generally upwardly away from opposed first and second longitudinal sides of the access port. A first flange is carried on the lower surface of the frame adjacent the first side of the access port and is pivotable between an insertion position and at least one retracting position. A second flange is carried on the lower surface of the frame adjacent the second side of the access port and is also pivotable between an insertion position and at least one retracting position. When the first and second flanges are in their retracting positions, they are adapted to urge upwardly against an internal surface of a patient""s tissue to seat the access port below the tissue""s upper surface. In one preferred configuration, each of the first and second flanges has a concave outer face adapted to face the internal surface of the tissue and retain the tissue between the flange and the lower surface of the adjacent wing.
As noted above, the invention also contemplates a method of gaining surgical access to a body cavity. One such method includes providing a surgical implant comprising a frame defining an access port; a first flange carried on a lower surface of the frame and having an elongate leading edge; and a second flange carried on the lower surface of the frame and having an elongate leading edge, the second flange being adjacent a side of the access port opposite the first flange. The leading edges of the first and second flanges are desirably positioned immediately adjacent one another to together define an elongate, generally linear leading edge of the implant. The operator makes an elongate, generally linear incision through the patient""s tissue, with the incision being at least as long as leading edge of the implant. The leading edge of the implant can then be inserted into the incision and a length of each of the first and second flanges can be urged through the incision. The first and second flanges can be urged laterally away from one another, thereby simultaneously expanding the opening through the patient""s tissue defined by the incision and centering the access port laterally within the opening.
In one further embodiment, the method also employs a resilient membrane having an external portion. Prior to the insertion of the leading edge of the implant into the incision through the tissue, the external portion of the resilient membrane is positioned over the patient""s tissue surrounding the incision site. After the flanges have been urged through the incision, and preferably after the flanges are urged laterally away from one another, the implant is withdrawn from the opening, leaving the resilient membrane in place over the patient""s tissue.
Yet another alternative embodiment of the invention provides a surgical tool mounting system including a frame and an insert. This frame is adapted to be attached to a patient""s tissue adjacent an access port through which a surgeon may gain access to a body cavity. The insert has an articulative joint and a variable-position brace. The joint is adapted to hold a surgical tool for use by the surgeon while permitting the surgeon to articulate the surgical tool with respect to the brace and the frame. The brace is adapted to be mounted on the frame in a first vertical orientation wherein the joint is positioned at a lower position with respect to the access port and a second vertical orientation wherein the joint is positioned at an upper position with respect to the access port. The joint in its lower position permits a broad range of motion of the surgical tool within the body cavity. The joint in its lower position permits a range of motion of the surgical tool within the body cavity which is more narrow than the broad range of motion permitted in the lower position.
Still another embodiment of the invention provides a surgical device for permitting improved access to a body cavity. This device includes a frame, at least two flanges, and a lever. The frame defines an access port and has a lower surface and a lever fitting. Preferably, the frame has first and second laterally extending wings carried on opposed first and second longitudinal sides of the access port. A first flange is carried on the lower surface of the frame adjacent the first side of the access port and is pivotable between an insertion position and at least one retracting position. A second flange is carried on the lower surface of the frame adjacent the second side of the access port and is pivotable between an insertion position and at least one retracting position. When the first and second flanges are in their retracting positions, they are adapted to urge upwardly against an internal surface of a patient""s tissue and retain the patient""s tissue between the flange and the frame. The lever is attached to the lever fitting of the frame to permit an operator to turn the frame to lift the patient""s tissue retained between the first flange and the frame above the patient""s tissue retained between the second flange and the frame.